Saving minutes in theatre: moving the risk, not removing it

What the paper says

Every anaesthetist knows the moment. The dressing is on, the next patient is waiting, and someone asks how long the patient will take to wake up, or remarks that they seem a bit slow to wake. Ironically, this sometimes follows a closure that has taken rather longer than the anaesthetic emergence ever will. This French study puts a number on that question.

The authors followed 756 adults having surgery at two university hospitals in France, where extubation in the post-anaesthesia care unit (PACU) is common practice. Two thirds of patients were extubated in theatre and one third in the PACU, at the discretion of the treating anaesthetist.

Extubation in theatre added about 8 minutes to theatre occupancy after the end of surgery. However, patients extubated in theatre were extubated around 28 minutes earlier, reached PACU discharge criteria 20–30 minutes earlier, and had less early desaturation (21% vs 36%), less need for supplemental oxygen (15% vs 29%) and less hypotension. There were no reintubations, and no difference in complications by day 7.

What is well supported

• The time cost of extubating in theatre is modest: under 10 minutes.
• Time saved in theatre is not saved overall. Patients extubated in the PACU spend longer there.
• Early desaturation and oxygen requirements were consistently lower after extubation in theatre, and this held after the authors adjusted statistically for the differences between the two groups.

What needs caution

• This is an observational study. Patients extubated in the PACU were heavier, more likely to have obstructive sleep apnoea or difficult-airway risk factors, and more likely to have had a laparotomy or a longer operation. The statistical adjustment balanced the measured differences, but clinicians chose the location for reasons that were not recorded.
• Even after adjustment, extubation in the PACU remained more common when another case was waiting. Production pressure, in other words, was part of the decision.
• The outcomes are soft. Desaturation was defined as SpO₂ below 96%, oxygen was given at clinicians' discretion, and ventilator settings, inspired oxygen and patient position before extubation were not recorded. Monitoring during transfer is also unknown.
• There are some internal inconsistencies between the text and tables, including the reported relative risks for desaturation and whether a sample size calculation was performed.
• The study was set in two French university hospitals and excluded after-hours and cardiac surgery.

My commentary

At first glance this study has limited relevance in Australia. Here, almost all patients are extubated in theatre, and transferring an intubated patient to recovery is uncommon. Its real value is as an answer to a familiar argument. When the list is running late and we are asked to hurry, the study suggests that the time saved in theatre is mostly time moved elsewhere.

The patient still has to emerge. If that happens in recovery, recovery staff manage it, a recovery bed is occupied for longer, and in a busy unit the next patient may wait in theatre for that bed anyway. The work does not disappear. It shifts downstream, along with some of the risk.

The same reasoning applies to two Australian habits.

The first is removal of a supraglottic airway in recovery. This is long-standing and widely accepted practice, and in suitable patients, with trained recovery staff and an anaesthetist immediately available, it is reasonable. However, it is worth being honest that emergence, and with it the risk of laryngospasm and airway obstruction, then happens in recovery rather than in theatre. That is a decision about where risk is best managed, not a free gain in efficiency.

The second is the Bailey manoeuvre, exchanging a tracheal tube for a supraglottic airway under deep anaesthesia. It is a valuable advanced technique. The Difficult Airway Society extubation guidelines describe it, alongside a remifentanil infusion technique, for patients in whom coughing and haemodynamic disturbance on emergence are undesirable.² A small randomised trial after craniotomy found smoother emergence, better oxygenation and fewer airway interventions than deep extubation.³ It also requires skill, an adequate depth of anaesthesia during the exchange and appropriate patient selection. It is not suitable for patients at risk of aspiration or in whom reintubation would be difficult.

Used to protect a neurosurgical or ENT patient, particularly where a remifentanil-assisted emergence is not being used, it may be good practice. Used to clear the theatre a few minutes earlier, its purpose changes. The patient then arrives in recovery deeply anaesthetised with a supraglottic airway, and the whole of emergence becomes recovery's problem. Some minutes are saved in theatre. The consequences are moved, not removed.

None of this means the theatre must always wait. It means the trade-off should be explicit. Where the patient is extubated, and how, should be decided for the patient's benefit, with the right staff and monitoring in place. Production pressure is a legitimate system concern, but it is a poor clinical indication. As this study shows, it may not even achieve its aim.

References

1. Godet T, Wajew C, Fabrizi M, et al. Impact of tracheal extubation location after surgical procedures on peri-operative times: a prospective dual-centre observational study. Anaesthesia 2025; 80: 915–26. doi:10.1111/anae.16620
2. Difficult Airway Society Extubation Guidelines Group; Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 318–40. doi:10.1111/j.1365-2044.2012.07075.x
3. Wei CF, Chung YT. Laryngeal mask airway facilitates a safe and smooth emergence from anesthesia in patients undergoing craniotomy: a prospective randomized controlled study. BMC Anesthesiol 2023; 23: 29. doi:10.1186/s12871-023-01972-x

This commentary is my own professional opinion, written for anaesthetists and other professional readers. It does not represent Alfred Health, ANZCA or any other organisation with which I am associated, and it is not individual medical advice. The original article is the work of its authors and is linked above.